Provider Demographics
NPI:1386915593
Name:SANTIAGO CANYON COLLEGE
Entity type:Organization
Organization Name:SANTIAGO CANYON COLLEGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COLLEGE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:E
Authorized Official - Last Name:YOCAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DO
Authorized Official - Phone:714-628-4773
Mailing Address - Street 1:8045 EAST CHAPMAN AVE
Mailing Address - Street 2:BUILDING T - 102 STUDENT HEALTH
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-4773
Mailing Address - Country:US
Mailing Address - Phone:714-628-4773
Mailing Address - Fax:714-628-4749
Practice Address - Street 1:8045 EAST CHAPMAN AVE
Practice Address - Street 2:BUILDING T - 102 STUDENT HEALTH
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-4773
Practice Address - Country:US
Practice Address - Phone:714-628-4773
Practice Address - Fax:714-628-4749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANTIAGO CANYON COLLEGE STUDENT HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20612103TC1900X
CAB307289163W00000X
CAZ0A8350207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty